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AetnaAll Plans · Coverage · Medical Policy · Pediatrics, Infectious DiseaseMedium impact

Nirsevimab-alip (Beyfortus) (CPB 1038, reviewed 2026-10-09)

Effective date
Sep 12, 2023
Identified
Oct 11, 2026

Summary

Aetna considers one intramuscular dose of nirsevimab-alip (Beyfortus) medically necessary to prevent RSV lower respiratory tract disease in infants under 8 months old born during or entering their first RSV season, and in children 8 to 11 months old at increased risk for severe disease, when the maternal RSV vaccine criteria are met and the infant has not previously received a clesrovimab-cfor, nirsevimab-alip or palivizumab dose. For the second RSV season, Aetna considers it medically necessary for children 8 to 19 months old at increased risk of severe RSV disease who have not received clesrovimab-cfor or palivizumab in the same season. All other indications are considered experimental, investigational or unproven.

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What to do

Action · 6 steps
01Billing team: Bill nirsevimab-alip using CPT 90380, 90381 or 90382, and only for infants and children who meet the criteria in this policy, with an ICD-10 code that supports the criteria (B20, B97.4, Q20.0 to Q28.9, Z29.11, Z95.1 or Z99.81).
02Confirm that the infant has not previously received clesrovimab-cfor, nirsevimab-alip or palivizumab, and that the maternal RSV vaccine status meets the criteria.
03Confirm the dose matches the policy's weight-based dosing: 50 mg for infants under 5 kg and 100 mg for 5 kg and greater in the first RSV season, and 200 mg given as two 100 mg IM injections in the second season.
04Palivizumab should not be given to infants who already received nirsevimab-alip in the same season.
05Only one dose per season is recommended, except the additional dose for children who undergo cardiac surgery with cardiopulmonary bypass.
06The extension of the administration period for the 2025 to 2026 season, often through April 30, 2026, has passed, so check current applicability with public health guidance before administering outside the October through March window.

Codes mentioned

9038090381903829637296380963813394633959364503645536456B20B97.4Q20.0Q28.9Z29.11Z95.1Z99.81

Original notice

Nirsevimab-alip (Beyfortus) (CPB 1038, reviewed 2026-10-09)
aetna.com · Always check the source before changing claims.
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Related changes

See all Aetna changes →
Nirsevimab-alip (Beyfortus) (CPB 1038, reviewed 2025-10-09)MediumNo effective date · Medical PolicyClesrovimab-cfor (Enflonsia) (CPB 1088, reviewed 2026-10-09)MediumEffective Oct 9, 2025 · Medical PolicyClesrovimab-cfor (Enflonsia) (CPB 1088, reviewed 09-2025-10)HighNo effective date · Medical PolicyRespiratory Syncytial Virus (RSV) Vaccines for Adult and Maternal Use (CPB 1027, reviewed 2026-10-09)MediumEffective Apr 11, 2023 · Medical PolicyBrowse every Aetna change in the policy list

Related policy hubs

Aetna policiesPediatricsInfectious DiseaseCode 90380Code 90381Code 90382Code 96372Code 96380Code 96381Code 33946Code 33959Code 36450Code 36455Code 36456Code B20Code B97.4Code Q20.0Code Q28.9Code Z29.11Code Z95.1Code Z99.81

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